Please use this form to update your child's emergency contact information for Fort Hamilton High School. A representative from the school will contact you to verify the information.

* Required

Student Information

Last Name: *

Your answer

First Name: *

Your answer

Middle Name:

Your answer

Date of Birth: *

MM

/

DD

/

YYYY

Sex: *

Your answer

Student's ID: *

Your answer

Parent/Guardian Information:

Parent/Guardian (Student resides with): *

Your answer

Relationship *

Your answer

Parent/ Guardian's Preferred Language of communication: *

Your answer

Written: *

Your answer

Oral: *

Your answer

Home Telephone: *

Your answer

Work Telephone:

Your answer

Cell No.: *

Your answer

E-mail

Your answer

Address: *

Your answer

Apt.

Your answer

City *

Your answer

State: *

Your answer

Zip: *

Your answer

Other Parent/Guardian:

Your answer

Relationship to student:

Your answer

Second Parent/Guardian's Preferred Language of Communication:

Your answer

Second Parent's Home Telephone:

Your answer

Second Cell No.:

Your answer

Second E-mail:

Your answer

Second Address:

Your answer

Second Apt:

Your answer

Second City:

Your answer

Second State:

Your answer

Second Zip:

Your answer

List three (3) persons who may be called in case of emergency or if child is sick in school.

CHILD WILL BE RELEASED ONLY TO PERSONS NAMED ON THIS CARD.

Name #1: *

Your answer

Phone Number #1: *

Your answer

Relationship #1: *

Your answer

Name #2:

Your answer

Phone Number #2:

Your answer

Relationship #2:

Your answer

Name #3:

Your answer

Phone Number #3:

Your answer

Relationship #3:

Your answer

If there is a person who may NOT HAVE ACCESS to child. please indicate:

No Access Name:

Your answer

Relationship to student:

Your answer

Order of Protection Exists?

Yes

No

HEALTH INFORMATION

Name of Physician/Clinic: *

Your answer

Telephone: *

Your answer

Does your child have any health conditions that may affect participation in physical activities? *

Yes

No

Limitations (e.g. , stair climbing, participation in gym) :

Your answer

Allergies:

Your answer

504 services for the current year? *

Yes

No

My child has: *

Private health insurance

Medicaid

No health insurance

If "No Health Insurance," are you willing to share contact information from this card to learn about insurance options?

Yes

No

If none of the named contacts can be reached, what do you wish the school to do if your child is sick or injured? It is understood that in the final disposition of an emergency case, the judgement of the school authorities will prevail. The recommendation of the parent as indicated above will be respected as far as possible.